To succeed, a health plan needs new capabilities, such as flexible network management and an unprecedented level of coordination between payers and providers. Payers must be agile enough to adjust network strategies on the fly, as they learn more about newly enrolled populations. They need the ability to administer more complex product designs, care delivery. and reimbursement initiatives quickly and efficiently.

Unfortunately, current network operations often struggle because of multiple sources of provider data, disconnected reimbursement systems, and manual loading between network management and contract management. As the need for administrative savings grows and networks and reimbursement arrangements increase in number and complexity, the problem with existing systems will increase.

The road ahead requires preparation and challenges to current assumptions. Here is a template for health plans to drive their activity on the health insurance exchange:

Strategic Review

What progress has been made toward the company’s health insurance exchange goals?

Who are the customers? What providers will be needed to meet adequacy requirements? Is a narrow network needed?

Network Requirements

How will the company maintain and report on an adequate network?

How will it re-evaluate customer needs once enrollment for 2014 is clear?

What care management and customer engagement is required?

Contract Modeling

Will there be re-contracting?

How will the company manage providers and other partners that want to leave the arrangement?

What is the coverage arrangement in member-centric models where members have more flexibility in their provider choice?

Reimbursement Configuration

Risk models: how will the plan differentiate among and pay providers based on member, location, specialty, role, etc.?

How will the claims system(s) handle the variety of reimbursement models coherently?

Does the current system architecture support the company’s health insurance exchange needs?

Does the company have the flexibility and automation for long-term success?

What are the requirements on how to share information with members on costs before services are rendered, and what information can be shared? How will the health plan meet these requirements?

Fundamental to any exchange activity is staying nimble as marketplace complexity increases with the roll-out. Network, contract, and reimbursement operations must be able to respond to change quickly, while improving synchronization and automation to keep pace.

Michael Flanagan is associate vice president for product management at McKesson Health Solutions. He has more than 14 years of product management experience and works with the company’s network and claim management tools.

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